DID WE DROP THE PENNY WITH HUMAN RESOURCE FOR HEALTH?

For the last 54 days, the health sector in Kenya has been paralyzed as a result of the doctors’ strike as they demand implementation of the collective bargaining agreement signed between the Ministry of Health and the Kenya Medical Practitioners, Pharmacists and Dentists Union in June 2013.

It has been a long road to this and as we take stock of the situation as it is today, it is critical that we understand the background. Medical training in Kenya started in July 3^rd 1967 at the University of Nairobi. Prior to this, our pioneer doctors were trained in Makerere, Asia, Europe and USA.

With the country in dire need of establishing a health system post-independence, the graduating doctors were highly regarded and every effort was made to retain them in public service. They were highly respected in society and though their pay may not have been very high, they were well taken care of. The government ensured they were housed in the finest civil service housing available, they were escorted by government vehicles when they needed to, they were provided with domestic help and their opinion was highly sought out in decision making.

The doctors were encouraged to go into specialization and their training was fully funded, whether this was in Kenya or outside the country. Though the doctors were bonded to work in the public sector for a while thereafter, they did not mind as they had favourable working conditions and they were allowed to do part time private practice to support the private health sector.

Fast forward to the beginning of the 80s and political unrest began to open the eyes of the many well learned employees in Kenya. The doctors first went on strike in 1981, protesting a government ban to private practice. Industrial unrest rocked the country culminating in the 1982 coup and the resultant ban in trade unions in the Moi Era.

In the 90s, the doctors began to agitate in earnest for better pay and improved state of public health facilities began, as inflation rocked the country, health care in the country became neglected and the privileges they enjoyed slowly faded off. This culminated in a four-month strike that paralysed the public health sector. They demanded registration of a doctors’ union to represent them. The response by government was swift and cruel. Many lost their jobs and their safety was threatened, leading to a mass exodus of doctors out of Kenya, mainly to the Southern African States, where most still reside or have died in exile.

The result of this response was that the new crop of doctors coming out of medical school were timid and did not dare stand up to authority much, despite being unhappy with the state of affairs in health. Behind the battle lines, a second medical school was opened in Moi University and in the 2000s, the privately sponsored university student emerged.

The privately sponsored medical students completely transformed the demographics of the newly graduating doctor. Whereas the earlier generation of doctors had gone to medical school on what was perceived as merit and were from all walks of life economically speaking, there was a subtle shift to most young doctors coming from well to do backgrounds. This was clearly spelt out by the fact that medical training is terribly expensive and only affluent families could afford to pay for this cost.

Within the medical schools themselves, the lifestyles of medical students started changing as evidenced by students who would drive to school, something unheard of as late as in 2000. The advent of the internet era fanned the flames rapidly as the medical students could compare themselves with colleagues outside Kenya in real time. This translated to the post-graduation attitude shift. The newly trained doctors realized that the salary paid at entry level could not even sustain them.

The industry came to a grinding halt in 2011, following the 2010 promulgation of the new constitution that strongly upheld the bill of rights (despite not having come into effect yet), as the doctors successfully lobbied for and registered a doctors’ union. The union called for its first strike in December 2011 that saw services paralysed in all hospitals in Kenya, save for emergency services ran by the specialists. The doctors had a litany of demands centred chiefly on improvement of the poor state of health care in the country and the poor remuneration they got for their skills.

The government responded positively by acknowledging the complaints. A road map for addressing these complaints was well laid out. The government agreed to give doctors an increment in allowances as a compromise to resume work while working on addressing the issues at hand. A task force made up of the union members and the government was set up. It came up with a blueprint for improving health sector services by compiling the existing ministry policy documents and making recommendations where policy did not exist. This is better known as the ‘Musyimi Task Force Report’ and it was completed in January 2012.

In the same year, the Ministry of Health as an employer, sat with the doctors union and after several months, came up with a successfully negotiated collective bargaining agreement to address the doctors’ remunerations, benefits, labour engagement with the employer and working conditions. The document was completed in early 2013 but orchestrated delays from the Ministry of Health led to its signing in June 2013.

The Ministry of Health failed to follow through with its mandate of registering the constitution in the industrial court; hence the CBA was never implemented. In October 2013, the health function was devolved in line with the new constitution but the exercise was marred by lack of structures and planning. The sector faced a lot of upheaval with services being severely disrupted. The health care workers all came together in December 2013 to strongly protest the devolution and for three weeks, the hospitals remained locked.

What followed was a Ministry that failed in its mandate to support the devolution process and strengthen the new county governments to enable them to embrace this function with ease. There was fragmentation across the country as counties were plagued with strikes, one after the other, with dissatisfied doctors looking for solutions to the never ending problems plaguing the human resource for health function.

From the onset, doctors decried the removal of the proposed health service commission (HSC) from the constitution. During the constitutional review process, the HSC was proposed to deal with matters of human resource for health. In the Wako Draft, the HSC was enshrined in Chapter 16, article 251 as follows:

Health Services Commission

251.(1) There is established the Health Services Commission.

(2) The functions of the Health Services Commission

are –

(a) to register trained health workers;

(b) subject to Article 248 to –

(i) recruit and employ registered health

workers;

(ii) assign health workers employed by

the Commission for service in any

public hospital and other

institutions; and

(iii) promote and transfer any such health

workers;

(c) ensure human resource development and,

professional standards and ethics for the

health service;

(d) to ensure registration of all health sector

professionals;

(e) to conduct medical audit and research;

(f) to ensure viable technical management

including procurement of services and

supplies;

(g) to oversee health care financing; and

(h) to perform any other functions conferred on

the Commission by an Act of Parliament.

 

With Failure of the first referendum in 2005, the subsequent reviews saw the wisdom of retaining the same up to the level of the Bomas draft. The HSC was retained in Chapter 16, Article 269 as follows:

Health Services Commission

269. (1) There is established the Health Service Commission.

(2) The functions of the Health Services Commission are –

(a) to register trained health workers;

(b) subject to Article 266 –126

(i) to recruit and employ registered health workers;

(ii) to assign health workers employed by the Commission

for service in any public hospital and other institutions;

and

(iii) to promote and transfer any such health workers;

(c) ensure planned health, human resources development,

professional standards and ethics;

(d) to ensure registration of all health sector professionals;

(e) to conduct medical audit and research;

(f) to ensure viable technical management including procurement

of services and supplies;

(g) to oversee health care financing; and

(h) to perform any other functions conferred on the Commission by

an Act of Parliament.

The HSC did not survive the Naivasha draft amendments and this is how health workers, delivering such an important social function, came to find themselves under county governance.

The road has been rough for most doctors under county public service boards. Many walked away to private practice, never to look back. The mushrooming of medical schools around the country provided refuge to many specialists as lecturers in the departments. The doctor left with limited options was the young newly registered medical/dental officer or pharmacist.

Months of unpaid salaries turned most into entrepreneurs, fuelled by the changing world of information technology, Most of them learnt to run online businesses to survive as they waited for the counties to have mercy and pay them. Many lived through horror stories of bullying by members of the county assemblies who were misguided into thinking they could tell a doctor how to do their job all the way to the wards. At one time or the other, they all relied on family to support them financially as they made endless trips to the county public service boards and the payroll managers to follow up on their salaries.

While going through these personal woes, they were subjected to hospitals that were terribly mismanaged. They would lack basic medical supplies and drugs required to save the lives of their patients, their senior consultants who guided them into the practice were resigning in droves, leaving them to haplessly fight for the patients on their own. County strikes with resultant victimization became the order of the day.

All these events were slowly but surely breeding a new monster. The doctors who spent their professional lives fighting for the patient progressively reached a point where they had to start fighting for themselves. Their bitterness brought them together to explore the option of pushing the Ministry of health to honour the CBA it had committed to. As the entity responsible for policy, the Ministry was expected to embrace its role and come up with policies that the counties would abide by in all areas, including human resource management. The CBA would be protected herein.

By the time the doctors were going on strike on December 5^th 2016, the country was dealing with a whole different set of doctors. These doctors were at the point where they had nothing to lose. They had survived so many strikes that no amount of intimidation by the government, threat of jail or absence of public support mattered. They had seen it all. Losing their jobs meant nothing if for the seven months they had worked in Nairobi County, they had never received a single month’s salary. Many had been forced by these circumstances to find alternative sources of income, hence stopping their salaries meant nothing.

The older doctors who are the current bunch of specialists, who had lived a lifetime of intimidation in the profession had reached the end. Seeing the resolve and dedication of their juniors awoke in them a long-buried fire. They came together and stood up for themselves, their juniors and their patients without fear. Something that the government had never counted on. Many who had previously been used by the administration to intimidate the young doctors, refused to comply this time round and stood up to their peers in management positions. They were firmly on the bandwagon.

It is common knowledge that revolutions have been led by people who share a common bond of oppression. Even the most timid will grow a spine when he sees the rest refusing to back down. For this reason, the strike has brought doctors together in a way that has never been seen before. The doctors are firmly in support of their leadership in a way never exhibited before. They are standing for each other spiritually and financially, like one big family, with establishment of welfare funds and social meetings to reinforce their resolve.

It therefore follows that the government must change tact. The old techniques of intimidation, divide and rule, threats of jail and withholding of priviledges is not going to work. Dialogue, good faith and good old common sense must prevail!

 

Photos courtesy of Dr. Michael Wachira